HomeMy WebLinkAbout01-25-10PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF Cu-~.~~1~~ COUNTY, PENNSYLVANIA
Estate of
also ktlown as
1~ o ire,-~.~s ,~ . ~-e ~z f ~-rn ~-r-,
File Number~~ _ ~~ i~~~
Deceased Social Security Number j ~ (~ " J~v~ -' ~3
Petitioner(s), who is/are 13 years of age or older, apply(ies) for:
(COtVIPLETE 'A' or 'B' BELOW.)
^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the
last Will of the Decedent dated and codicil(s) dated
named in the
(State relevant circumstances, e.g., renunciation, death of executor, etc.) N
.. ~_ .
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution theme instrumet4€~5) offei`ed:
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: =~ -~ ~ f"~`'
i "{ { --~ ~.. .
B. Grant of Letters of Administration
(Ifapplicable, enter.• c. t. a.; d. b. n. c.t.a.; pertdentelite; duranteabsentia; duratke"rrrtirs ritctte) "''C?
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spb~.tsif any) an~teirs: '(If
Admirtistratiott, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) ~ ~ '~
• ?°' ""
Name
mPllln~ ~ L . rte,
Relationshi Residence
~~~r ~ h ,'cs ,
(COMPLETE IN ALL CASES:) Attach additional sheets if ~tecessary.
/~ecedent was domiciled at death in Y>7 bG~' n County, Pennsylvania ith his /her last principal residence at
~2Q, ~ rvd GG~~(( .q-v~~ nom- ~...r m~.~ .~z~-~ , ~i4 > `7U ~ 3
(List street address, town/city, township, county, state, zip code)
Decedent, then ~~ years of age, died on J'I~CU't/~ ~ ~~~f at
5. 3 J~ a ~ ~LCGt- l'-C St f G't Q n c..=--G_.-
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
(If not domiciled in PA) Personal property in Pennsylvania
{If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
~ 5~~, ~~
e
e
Whe~•efore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
l Si
~v r
a
or printed name and residence
t C.' h are ~ c-~~ ~~~- ~ ~~ I'7v Sa
Form RlV-0? rev. /o.r3.o6 Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF ~~ ~,~-~-Y, J~.PA-- I Q.n d
The Petitioner(s) above-named swear(s) or affirnz(s) that the statements in the foregoing Petition are true and correct to the best of
the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
before me the ~ day of
~ ~
or the Register
~
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%Lt.c. c~
ignature ojPersonal Representat ve ~ o
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Signature ojPersa,al Representative ~ CT"1
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Signature oJPersonal Representative ~ ~ r ~ _'
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File Number: ~ ~ - I ~ ' Q O~
Estate of~~Ot--~.S {~. t`Pa ~~-~ OLD ,Deceased
Social Security Number:'ln~ ~' ~ -~ ~") 9 Date of Death: ~~ J " ~~
AND NOW, 5 , o~G~ l ~ , in consideration of the foregoing Petition, satisfactory proof
having been preset e before me I DECREED that Letters ~~ ~ ~ ~ ~~--~-~-t ~ ~
are hereby granted to_~ d .d11 ~ ~ ~,~'YZ. ~~- ~
r
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last
FEES
Letters ............... $ ~ ~ .
Short Certificate(s) ........ $_ ~ ~ . L}~
Renunciation(s) .......... $ U~
JCS ... ~~3 ~~
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $ t
in the above estate
and Codici)w(s)) of Decedent.
Register of Wills
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
r-»,~», Rw-v? rev. rv.l.~.vr Page 2 of 2
RENUNCIATION
REGISTER OF WILLS
Cumberland
COUNTY, PENNSYLVANIA
Estate of
Dolores Anne Fealtman
Deceased
I, Regina Ann Smith , in my capacity/relationship as
(Print Name)
daughter of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
Melanie Lynn Smith
January 5, 2010
(Dare)
l~~ ~~~J S,~v~Nd~fl
~~ '~~~i~
121 Walnut Drive
(Street Address)
Scott Depot, WV 25560
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
(Signal )
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this ~~_ day
of ~ , ~7c,~ ~
Notary Pic
My Commission Expires: ~~~~ ~~ ~ ~ ~ `~
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
z ~ : ~ ~~ ~z ~~r o ~ a~
NOTAaY -YiftlC OFFICIAL TEAL
--, , ~ ~ E-• , ~ ~, STACEY D. MOSS
Form RW-06 rev. 10.13.06 Stets of W~at Virpinls
'' i "~' - ' ~ Mfr Commisabn Expirea
"' ` ' Aupuat 23, 2014
''~~ ~~ ~i ~~~' s~.~'...i J,,,, ~ -' 2306 Emmons Roaa
Alurn awk, WV 2b003
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 15187608
Certification Number
TEEM # /
_~ULDAEAIZASEQLLQA~S _ _ _
~.>Z ~e-
REV 11/2006
PRINT IN
1ANENT
,K INK
r.'---
5. Age (Last BirhWay) Under 1 ar
Mortara Daya Under 1 day
Hours Minutes 6. Date of Birth (Month, day, year) 7. Birthplace (Ci ant stale a 1 count )
54 Yre. Dec 28 1954 Willow Gro P
la. Place of Death (Check onw orwr
8b. Court of Death
ty
8c. City, Boro, Twp. of Death ve a
8d. Faadty Name (d rat irrstitWion, give streM and number) ~] Irrpetient ^ ER /Outpatient ^ DOA ^ Nursing Home ~ Residence ^Other . specity:
Cumberland
E, Pennsboro Tw
12 Railroad Ave
S
m
d
l 9. Was Decedent of Hispanic Origin? [~ No ^ Yes
(IfYas'aloedtyc~ean, 10. Rxe: American Indian, Black, White, etc.
(~~
11. Decedent's Uars>f don Kind of wok done drain most of wo INe. Do rat state retired
K
12. Was Decedent aver in the ,
u
mer
a
e,
13. Decedent's Education
(qty ~ highest
rade com
l a
Mexica
t
d n, Puerto Riran, etc.) Whit e
ind ~ Work
Homemaker Kind of Business !Industry U.S. Armed Forces?
Elementary /secondary (0-12) g
p
e
e
)
College (1.4 or 5+) 14. WMowed, Divo married, Never Marred,
l~bl 15. Surviving Spouse (If wife, give maiden name)
16. Decedent's Mailkg Address (Street, city /town, s
tate, zip code) ^Yes ~"°
Decedent's U k Divorced
1 2 Rai 1 r o a d Ave Actwl Residence 17a. State Did Decedent
Pennsylvania o
„c.~ yea, Decedent LNed in
East P ri n ~ hn r n
Summerdale
Pa 17025 _
p~
Twp
i7b.County Cumberland 17d.^No,DecedentUvedwhhin
18. Famer's Name (First, midde, last, aufrix) Actual Limits of City / Boro
'
John F, Kerstan 19. Mother
s Name (First, miride, maiden wmame)
20a. Infomrent's Name (Type /Print) Anna E. Martin
Melanie L
Smith lob. InMnnanrs Mailing Address (street, °„y /'°,„'' state, :ip r:~e)
2,a.MethodofDleposhbn .
~] Cremation ^ Donelbn
21b
D
t
f Di 5510 Silvercreek Dr, Mechanicsburg, Pa 17050
^ Bunal ^ Removal Irom State
~ Was Cremation or Donation Authorized .
a
e o
sposition (Month, day, year) 21c. Place of Disposition (Name of cercretery, crematory a odrer place) 21d. Location (Chy /town, state, zip code)
^ Other - Speclly
22a. Signor d Servic
(a by Medal Exntrrirar / Cororrsr9
raon such)
Yea^Nu
22b
Li
3/2/09
Evans Cremation Service
Leola Pa
e
~ .
cense Number 22c. Name end Address of FadYty
Sullivan Funeral Home
Complete h 23ec ony when cart '
h
id
i
23a. To the best of ,death occurred FD011897-L
at dre time, dale and place stated. (Signa 51 N, Enola Dr. Enola Pa 17025
ture and title)
p
ys
en
e rat avaiiable at time of death to
~eroly Sawa of deem.
C,~~ ~ 23b. License Number
~ ~ ~~ ~ 3~1 23c. Date Signed (Month, day, year)
hems 24.26 must be
completed by person 24. Time of Deem
25. Date P
(M
o
nth day, year) C~ L ~ ~r~~~
who pronaeaes deem.
~ a 2b M
c•+ /~
y
~
W ~ ~ ~
`
'
~~/'~ 28. Was Case Referred to Medal Examiner /Coroner for a Reason Other than Cremation or Donation?
^ ~
Yes
CAUSE OF DEAtH ( instru V
-
ctions and exam
l o
p
es) r Approximate interval:
Nem 27. Pan I: Enter the chart of events -diseases, injuries, acomplications -drat dxecdy cawed the deaM. DO NOT enter terminal evenb such as cardiac arrest
re
i
t Part II : Enter other '
~
28. Did Tobacco Use Contrib
t
t
D
m?
sp
ra
ory arced, a ventricular , r
dbriAataut showing the etiobgy. List Onset to Deem
onty one cave on each line. t
ng the urWe
but rat resuhi m Hying cause given in Pan L u
e
o
ea
^ Yes ^ Probably
IMMEDIATE CAUSE (Final disease a
condition resulting in deem)
-1• a. _ r
,'
t
I 19 1 /''i
~~ f: 1 A ~ ~L IO~ ~
R j l
r
M1 ~ ^ Na ^ Unkrawn
,
i
Q ;
1
, Y 1111 ~l F~rJ1,/11Cr
Due to (a as consequence oq. r
29. II Female:
Segrenf~apy list crorrdliorrs, if any, b.
M to the cause listed on line a.
Enter UNOERLY ~
Due t ^ Not pregnant within pest year
^ Pregnant at tim
f d
m
MIG CAUSE
r~ry ryry ~t ~~~~ a c.
m9 m death o (a as a consequerce of): i
~ e o
ee
^ Not pregnant, twt pregnant within 42 days
Due to (or as a consequence ot): r of death
d. ~ ^ Not pregnant, Ixd pregnant 43 days to 1 year
30e. Was an AWOpsy
Performed?
30b. Were Autopsy Flrrdings
Available Prior to
Completion
of Cause of Death?
31. Ma Her of Deem
Natural ^ Homicide r
32a. Date of krjtrry (Monet, day, year) 32b. Describe How Injury Occurred before deem
^ Unknown it pregnant within the past year
32c. Place of In hlorcre, Farm, Street, Faq
1!xY Dry
~ ,
OBice Buildng, etc. (Spea'fyJ
^ Yes No
/ ^ Yes ^ No ^ Accident [~ Pendkrg Investigation 32d. Time of Injury 32e. Inryry at Work? 3N. II Transportation Injury (Specity) 32 Location of In u Street
9• I ry ( city /town
state)
^ Suicide ^ Could Not be Detemrkred
M.
^ Yes ^ No ^ Driver /Operates ^ Passenger ^Pr'destnan ,
,
Omer - Speaty:
33a. Certifier (check Doty one)
• 33b t e and T41e o(C nfliar
Csrdfyfng physician (Physician cenilying cause of death when another Imysidan has prorrourrced deem and completed Item 23) , I / 3 f 'T~7"/
To the best of my knowledge, death occurred due to the cause(s) end manner as stated,. _ _ _ _ _ _ _ t ` (`,./J".°,,"y'~
• Pronouncing end certilytng physiclen (Physician botlr pronorxaing death and certiying to cause d death) - - - - - - - - - - - - - - - - - - - - - - - - -
To the best of my knowledge, death occurred at the time, date, and plea, and due to the cause(s) and manner as etated_ _ _ _ _ _ _ _ _ _ _ _ ~ ^ ~ License Number
• Medleal Examiner /Coroner , ^ ^ r~ ~ Z r ~ (V
On the beats of exsminatlon and / or inveetigatlon, in my opinbn, death occurred at the time, date, and plea, and due to the cause(s) and manner as staterL ^ Y v' j~
34. Name and Address W Person Wh Completed Cause
Registrar's Signature sbict Number /
!.r ~ ., i~. a ._ 1~ r. _
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
~.,.., MAR 0 21009
Local Registrar Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE
2 Sex 3 Social Sec
c-~ -_ ,.
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car ~.:.~ _ _.
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Do 1 ore s A , Fe 1 tma ri udty Number 4. Date of Death (Month, day,
Female 1 66 -52 ~- 5379 3/1 /09
'I~1~ ,VV~
3 ,~
33d. Dale Sign d (Mont ,day, year)
(Item 27a Type /Print
it~(Sl~~:-~--'
J 7,
Disposition Permit Na.